Dissertation

Welfare of adult caregivers in domiciliary and
residential services
J02024
Psychology (conversion) MSc part-time
PS7112 Research dissertation
2014/2015
University of Chester
Supervising tutor: ……………….
Word count: 12,610

Abstract
Domiciliary and residential caregiver well-being was examined in response to reports of
improper organisational support practices. Caregiver susceptibility to anxiety and
depressive symptomology were examined. Additionally, to what extent internal locus of
control, affective and cognitive empathy, perceived organisational support and self-
esteem could predict anxiety and depression within these populations was explored. A
between-subjects cross sectional design was used to compare self-report
questionnaire response data from UK domiciliary (n=51), residential (n=85) and a non-
caregiver control groups (n=67). Hospital anxiety and depression scale scores showed
that caregivers were more susceptible than non-caregivers to anxiety and depressive
symptomology. Tukey’s post hoc analysis confirmed one statistical difference between
high domiciliary and low control depression scores (p=.01). Correlation analysis
indicated one negative association between perceived organisational support and
depression. Hierarchical multiple regression analysis established low levels of internal
locus of control (p<.001) and increased affective empathy (p<.02) to be statistically
significant predictors of anxiety. Similarly, low levels of internal locus of control (p<.001)
and domiciliary occupation type (p<.001) were found to be statistically significant
predictors of depression. However, findings must be interpreted with caution due to the
small size and distribution range of the questionnaires. Furthermore, anxiety and
depression scores were below clinical range. These, findings do not fully substantiate
an association between the impact on caregiver well-being and the perception of
negative organisational practices. A questionnaire designed from focus group
outcomes of caregiver organisational support perceptions may be a more accurate
method to access the impact poor organisation support has on caregiver well-being.

Introduction
The consequence of outsourcing publically funded social care to the
independent sector is the competition between financially orientated residential (res)
and domiciliary (dom) providers who ultimately drive out the good providers (Koehler,
2014). As such, the consequence of poor care will be paid for by the elderly, the
vulnerable, and by the caregivers they depend on (CQC, 2014; Koehler, 2014). When
considering the projected increase in need of care due to greater life expectancy, better
health care, and rise in population (National Audit Office, 2014) employers have an
operational and moral responsibility to safeguard their staffs’ psychological well-being.
Previous res and dom caregiver health and well-being research focused the
requirement for staff retention and financial and practical support form organisations to
maintain the health and social care needs for those they care for (Castle & Engberg,
2007; Chester, Hughes & Challis, 2014; Colton & Roberts, 2007; Denton et al., 2002;
Eustis, Kane & Fischer, 1993; Hunter, Ward & Camp, 2012; Wibberly, 2013). However,
the challenge to implement change appears to remain difficult in light of recent think
tank (Franklin, 2014; Koehler, 2014), National audit office (National Audit Office, 2014),
The National Care Forum (The National Care Forum, 2015), employer-led workforce
development bodies (Skills for Care, 2015) care quality inspectorates (CQC, 2013,
2014; CSSIW, 2014) and increasing media reports (for example, Daly, 2008; Farooq,
2009; Triggle, 2014, 2015). Perhaps by redirecting the focus of this research to
ascertaining imbalances in caregiver psychological well-being, poor service providers
may re-access their stance on negative operational practices.
Definitions
Characteristically, a res caregiver will provide a number or person centred
social, personal and domestic care duties to a variety of vulnerable individuals (for
example, learning disabilities, elderly, dementia and mental health) in a single place of
work generally following a regular shift pattern. A dom caregiver undertakes similar

duties to a variety of care receivers’ with similar needs over the course of a day but
within their own homes to maintain independence and quality of life. A dom caregiver
will usually work irregular hours, irregular shift patterns and is required to provide their
own transport between calls. Demographically, females account for 83% of the dom
care workforce. The average age of a dom caregiver is forty two. Furthermore, 37% are
understood to work part-time with 23% on a zero-hours contract (Skills for Care, 2015).
These figures are comparable to prior research (Zeytinoglu, Denton, Davies &
Plenderleith, 2009) as is the disproportion in gender and age (Crown, Ahlburg, &
McAdam, 1995), indicating consistency in demographics over time that are also
comparable to res caregiver figures (CQC, 2014; Skills for Care, 2015). Recent data
exposed the comparable rates in staff turnover between these two groups (CQC, 2014;
Koehler, 2014; National Audit Office, 2014; The National Care Forum, 2015; Skills For
Care, 2015). Of the three hundred thousand social care workers leaving their role each
year, this data indicates that adult dom caregivers account for 30.6% of leavers
compared to 24.2% adult res caregivers (Skills For Care, 2015). It is estimated that
whilst 42% continue to work in this sector 58% leave altogether. (Skills For Care,
2015). Such similarities between the two groups make them ideal for comparative
analysis. Likewise, the addition of a non-caregiver group (control group) as used in
previous well-being research (Butterworth, Pymont, Rodgers, Windsor & Antsey, 2010),
provides a reliable baseline with which to compare the two groups.
Review of the literature
A systematic review of the literature suggests that anxiety and depression
appear to be the most common consequences of caring for a vulnerable adult (Blanco,
Rohde, Vázquez & Torres, 2014; del-Pino‐Casado, Pérez‐Cruz, & Frías‐Osuna, 2014;
Otero, Smit, Cuijpers, Torres, Blanco & Vázquez, 2014; Rodakowski, Skidmore,
Rogers, & Schulz, 2012). Both reported to have greater impact caregivers than non-
caregivers (Butterworth et al., 2010) with a focus on the research based around

caregivers of the frail and elderly (Aggar, Ronaldson, & Cameron, 2011; Phillips,
Gallagher, Hunt, Der, & Carroll, 2009; Silva, Teixeira, Teixeira & Freitas, 2013),
dementia caregivers (Edwards, Zarit, Stephens & Townsend, 2002; Hatch, DeHart,
Norton, 2014; Molyneux, McCarthy, McEniff, Cryan & Conroy, 2008) learning disability
(LD) caregivers (Gray-Stanley, Muramatsu, Heller, Hughes, Johnson, & Ramirez-
Valles, 2010; Li, Shaffer and Bagger, 2015; Minnes, Woodford, Passey, 2007; Mutkins,
Brown & Thorsteinsson, 2011; Taggart, Truesdale-Kennedy, Ryan & McConkey, 2012)
and some research based on mental health (MH) caregivers (Cummings & Kropf,
2015; Taylor & Barling, 2004). Such consequences are also recognised cross culturally
(Rezende, Coimbra, Costallat & Coimbra, 2010; Wang, Shyu, Chen & Yang, 2011).
This body of research suggests that regardless of the caregiver’s health or disability
status, it is the role of having to care for vulnerable adults that cause anxiety and
depressive symptomology. As such, research indicates that there is great relatability
between anxiety and depression. Notably, that one will usually predict the other (Aggar
et al., 2011; Phillips et al., 2009).
However most of this research focusses on paid MH caregivers and unpaid
family caregivers. The impact on family caregivers’ psychological well-being can be
interpreted by their own individual means to find a balance between life, caregiving and
work (Wang et al., 2011). Contrarily, Edwards et al. (2010) found there to be no
difference in role overload, worry, strain, and depression between employed and non-
employed caregivers. Suggesting that employed and family caregivers can be
susceptible to similar psychological imbalances regardless of the caregiver’s personal
or professional relationship.
Psychological variables
Perceived organisational support (POS). POS relates to the value of the
employee employer relationship. Here, the employee recognises their worth in relation
to the organisations operational goal, enabling the caregiver to proficiently complete

their job roles and to effectively manage demanding circumstances (George, Reed,
Ballard, Colin, & Fielding, 1993). Similarly, organisational support theory stipulates that
employees must develop a belief that the organisation values their contribution and
well-being before the organisation will recognise and subsequently reward them
(Eisenberger, Huntington, Hutchison, & Sowa, 1986). A positive reciprocal relationship
between employee and employer is believed to satisfy the socioemotional need of the
employee in terms of esteem, affiliation and approval (Rhoades & Eisenberg, 2002). An
absence of this in residential services has led to reductions in job satisfaction, positive
mood, affective commitment and a performance increasing staff turnover (Castle &
Engberg, 2007; Colton & Roberts, 2007; Rhoades & Eisenberg, 2002). Similarly,
research has found that low organisational support and depressive symptoms to be
associated with burnout in LD services (Mutkins et al., 2011). Not just related to private
companies, compared to charity home care staff, home care NHS staff believe that
organisations had unrealistic expectations and perceived that their views are not
listened to (Blumenthal, Lavender & Hewson, 1998).
Quality assurance research indicates that there are a number of fundamental
pre-requisites required from caregivers by their organisations in order to deliver
appropriate care. For example: appropriate training, adequate pay, good
communication, contact with peers and supervisors, supporting documentation and
information, supervision, and clear accountability and authority (Eustis et al., 1993).
Results from a meta-analysis of 70 studies concerning POS found that fair treatment,
favourable job conditions, supervisor support and rewards were significantly related to
POS (Rhoades & Eisenberg, 2002). However, personality and demographic
characteristics were weakly associated. Equally, subcategories of organisational
rewards found that job stressors and job security had a strong relationship with POS.
As such employees with a high POS commonly suffer fewer strain symptoms including

burnout, anxiety headaches and fatigue as well as job satisfaction (Rhoades &
Eisenberg, 2002).
It would appear beneficial to the welfare of the caregiver to adhere to these pre-
requisites. However a vast number of reports do not reflect this. Concurrent, figures
indicate a disproportionally high use of zero-hour contracts amongst res and dom
caregivers (Skills for Care, 2015). Whilst they offer employers more flexibility to
respond to the fluctuation in care demand (CSSIW, 2014) they simultaneously impact
on job insecurity destabilising caregivers’ lives and incomes (Koehler, 2014). Job
insecurity has affected job competition in MH services leading to burnout and work
related stress exacerbated by poor management and inadequate resources (Taylor &
Barling, 2004). Contrarily research has indicated that zero-hour contracts suit some
caregiver’s lifestyles (Eustis & Fischer, 1991). Growing reports reflect the inequality in
pay particularly amongst dom caregivers met attributable to a lack of fuel and uniform
allowance (Koehler, 2014; National Audit Office, 2014; Skills for Care, 2015) known to
impact well-being (Denton et al., 2014). Furthermore, non-specified sick pay and
payment fort training within social care contract documentation (Chester et al., 2014)
could further impact on financial burden and sense of feeling devalued by the
employer.
Likewise, training and work related qualifications within dom and res services
are low (Franklin, 2014; Colton & Roberts, 2007; Skills for Care, 2015). Whilst training
has led to caregiver positivity, simultaneously impacting on turnover rates seen in a
residential study (Hunter et al,, 2012), its absence will undoubtedly risk both caregivers
and care receiver’s well-being when encountering challenging behaviours (Denton et
al., 2002; Rose, Mills, Silva, Thompson, 2013). This is notable in cases of dementia
(Hatch et al., 2014; Molyneux et al., 2008), LD (Minnes, et al., 2007; Li, Shaffer &
Bagger, 2015) and MH (Taylor & Barling, 2004). By reinvesting back in staff training
caregivers will be more equipped to deal with challenging behaviour (Denton et al.,

2002) and reinforce POS (Shore & Shore, 1995). Similarly, working in dirty and unsafe
homes due to insufficient times to clean has been linked to the devaluation of caregiver
work and risking well-being (Wibberly, 2013), believed attributable to organisations
purposely cutting down times between clients to increase profit (Daly, 2008; Farooq,
2009; National Audit Office, 2014). Subsequent time pressures to complete roles are
shown to lead to stress (Michelson & Tepperman, 2003; Taylor & Barling, 2004) and
are associated with depression and an inability to control one’s life events (Gray-
Stanley et al., 2010). However it is important to understand that this is not the status
quo and there are numerous accounts of good service provision in the UK (CQC, 2013,
2014).
A review of the literature has highlighted the requirement for fair treatment and
retention of quality caregivers through policy change (Chester et al., 2014; Denton et
al., 2002; Eustis et al., 1993; Franklin, 2014; Koehler, 2014; Skills for Care, 2015). As
such, social, legal and financial intervention support strategies (Hatch et al., 2014; Silva
et al., 2013) have helped to reduce emotional stress (Otero et al., 2014), physical
fatigue (Phillips et al., 2009) and caregiving resentment (Aggar et al., 2011) amongst
informal caregivers.
Locus of control. Locus of control (LOC) revolves around an individual’s
internal and external belief in which they can control the outcomes of life events
(Rotter, 1966). Commonly, an internal LOC relates to the belief that a person can
influence their own outcomes and are mostly in control of what happens to them. An
external LOC is the belief that an individual is not in control of live events subsequently
perceiving negative consequences as a result of luck or chance that is out of their
control (Gray-Stanley et al., 2010; Rotter, 1966). Internality of control has been related
to coping strategies that manage stress (Hay & Diehl, 2010) and increased self-esteem
(Anderson, 1998) which in turn relates to psychological adjustment (Elfström & Kreuter,
2006). Those who subscribe to external LOC endorse higher levels of stress, illness

and lower levels of self-efficacy (Roddenberry & Renk, 2010). As such external LOC is
associated with depression (Presson & Benassi, 1996) and anxiety (Molinari & Khanna,
1981).
In relation to the caregiving context, a study by Chan (2000) found those with
an internal LOC to have greater life satisfaction, less caregiver burden, low levels of
depression and greater role satisfaction due to greater coping strategies. Similarly,
higher internal LOC scores lead to a better quality of life and fewer depressive
symptoms (Gibson et al, 2013). It is said that those overoptimistic individuals purposely
attribute negative life events to external outcomes to as a method of protection to
maintain control (Seligman, 1991), suggesting that there is some interchangeability
between the two concepts (Lefcourt, 1991). As such it is plausible to assume that low
levels of internal control can impact on psychological well-being dependent on the
situation. Current negative caring cultures deter autonomy of care, career progression
and maintain a status quo of low status (Koehler, 2014) controlled by a lack of pay,
poor management and a lack of training (Eustis et al., 1993; Koehler, 2014). This
cyclical nature known to impact on job satisfaction, stress, self-esteem and resentment
(Colton & Roberts, 2007; Denton et al., 2002; Taylor & Barling, 2004; Michelson &
Tepperman, 2003) will undoubtedly impact on the perception that one believes they are
in control of their lives. However, the perception of some caregivers’ situation may not
be related to fate or chance but to an acknowledgement that they are not being
supported appropriately. This reflects the work by Lefcourt, Martin, & Saleh (1984) who
believed that those with an internal LOC compared to those with an external LOC
benefit from social interactions and support, suggesting that this is a possible coping
method to relieve stress. As such internal LOC has been associated with greater social
support that was significantly correlated with better psychological health and lower
levels of perceived stress in the caregiving context (Pelletier, Alfano & Fink, 1994). In

this instance it is plausible to assume that low levels of internal control can relate to low
levels of psychological well-being.
Self-esteem. Self-esteem is a universal assessment of self-acceptance, self-
satisfaction, self-respect, and self-worth (Bowling, 2005). Stability in self-esteem is
related to reduced mood swings (Campbell, Chew, & Scratchley, 1991) and happiness
(Galambos, Fang, Krahn, Johnson, & Lachman, 2015). Also, high and low levels of
self-esteem has found to impact significantly on success and failures in life domains
(Orth, Robins & Widman, 2012). Similarly, the absence of self-esteem is related to a
number of psychological symptoms including depression (Riketta, 2004; Sowislo, Orth
& Meier, 2014; Zunzunegui, Llácer, & Béland, 2002) and anxiety (Lee & Hankin, 2009;
Riketta, 2004). A meta-analysis of the available literature suggests that the effect of low
self-esteem on depression in robust across time, samples and characteristics (Sowislo
& Orth, 2013) seemingly related to the exposure of stressful events (Orth, Robins, &
Meier, 2009) and daily hassles (Kernis et al, 1998).
Characteristically, greater self-esteem levels have been attributed to women
with a higher educational status than those who have not, who had embraced religion
in childhood and who have a greater sense of LOC in the caregiving context (Moen,
Robinson & Dempster-McClain, 1995). Furthermore, Moen et al. (1995) also found that
those women who had life satisfaction and self-esteem prior to obtaining a caregiving
role managed to retain self-esteem and well-being. High self-esteem is important in the
provision of care because it is essential to the reciprocity of the caregiver and caregiver
relationship (Kramer, 1997; Lopez, Lopez-Arrieta & Crespo, 2005; Neufeld & Harrison,
1995). Maintenance of self-esteem is particularly important when dealing with difficult
and stressful situations related to the complex need of passive or aggressive care
receivers (Colton & Roberts, 2007; Molyneux, et al., 2008; Rose et al., 2013). In order
to maintain self-esteem organisations must provide holistic support to their caregivers
as suggest by a recent think tank report: self-esteem is important to the caregiver

workforce suggesting that in order to provide compassionate care; greater training, free
influenza vaccinations, key-worker status, working carer tax credits, appropriate pay,
licence to practise for all homecare workers and the promotion of career pathways are
required (Koehler, 2014). Currently, res and dom research suggest that there is a lack
of such operational and social organisational support (Colton & Roberts, 2007; Denton
et al., 2002; Mutkins et al., 2011). As such, research suggests that those whose self-
esteem is dependent on workplace performance are likely to feel ostracised in the face
of poor performance (Lance Ferris, Lian, Brown & Morrison, 2015). Equally, self-
esteem has been shown to moderate workplace conflict and role strain (Dijkstra,
Beersman & Cornelissen, 2012), thus having a direct impact on the ability to provide
compassionate care for the caregivers. Research has shown that by emphasising
mutual respect (Lyons, Sayer, Archbold, Hornbrook, & Stewart, 2007) and
readdressing the imbalances in caregiver and care receiver relationship can strengthen
caregiver resolve and resilience leading to greater levels of satisfaction, reward and
happiness that ultimately reinforces and strengthens the bond between caregiver and
care receiver (Brouwer, van Exel, van den Berg, van den Bos, & Koopmanschap, 2005;
Chappell & Dujela, 2008; Cohen, Colantonio, & Vernich, 2002; Kramer, 1997).
However, without readdressing negative organisational practices this will only
exacerbate caregiver MH deficits (Denton et al., 2002; Eustis et al., 1993).
Empathy. A modern day conception of empathy is based around two
components: affective empathy and cognitive empathy (Davis, 1983; Jolliffe &
Farrington, 2006) measured by the basic empathy scales (BES) (Jolliffe & Farrington,
2006). As such, empathy is recognised as an automotive response as well as an
interpersonal attentive cognitive reaction to the emotions and mental states of other
individuals (Carré, Stefaniak, D’Ambrosio, Bensalah & Besche-Richard, 2013).
Recognising that the scale was initially designed for adolescents, through its
development and validation Jolliffe and Farrington (2006) found that females scored

higher in both empathy components through particularly higher in affective empathy.
Similarly, females were more likely to respond prosocially to another individual’s
distress compared to males. Whilst it is recognised that a residential or dom caregiver
role is not financially rewarding the choice of a caring career pathway may instead be
prosocially incentivised noting the large disproportion of male caregivers to female
caregivers (Skills for Care, 2015). As such, in a caring context empathy is essential to
producing the right socioemotional therapeutic response (for example, comforting the
individual when they are upset or proving sensitive personal care not leaving it for
someone else to do) interpreting the care receivers’’ emotional and contextual state.
Well supported caregivers experience great satisfaction and reward from their
caregiving roles (Hatch et al, 2014; Silva et al., 2013) many individuals that become
report enjoyment, companionship and others find a great sense of reward, fulfilment
and enjoyment out of being able to provide a quality of life (Cohen et al., 2002). The
reciprocal nature of this relationship is based on self-awareness, non-judgmental
approach requiring a mutual regard (Davis, 1990).
Austin, Globe, Leier and Bryne (2009) compared a reduction in empathy to a
term called ‘compassion fatigue’ where by one’s ability to empathise with another’s
psychological distress is hampered by redirecting the caregivers focus on themselves
attributed to psychological issues including burnout, stress and emotional contagion.
Similarly, barriers to relive another’s emotional distress (for example, less time with the
care receiver) may induce a corresponding response. For example, it may impact on
caregivers’ emotional state including anxious feelings or tension at their inability to
perform their job. However, this may be interpreted as a sympathetic not empathic
response if the caregiver cannot transpose themselves into the care receiver’s position
(Davis, 1990). As such, research appeals for caregivers to participate in perspective
taking to influence one’s interpretation of what another person is experiencing
(Lobchuk, 2006).

Factors related to the maintenance of empathy include, patient recovery,
professional support, personal support, professional resources and compassion
satisfaction (Austin et al., 2009). As discussed res and dom are equally susceptible to
burnout (Blumenthal et al., 1998), stress (Gray-Stanley et al., 2010) and other
psychological symptomology due to negative organisational practices (Mutkins et al.,
2011) and challenging nature of the work (Rose et al., 2013; Wibberly, 2013). Whilst
most empathy research is based around nurses and their care receivers (Austin et al.,
2009; Lobchuk, 2006), it is plausible to assume that res and dom caregivers
experience reduction in empathy levels due to similar roles and responsibilities.
However, a review of the research has not found any substantial accountancy of
empathy to anxiety or depression. Given the impact POS, LOC, self-esteem and
empathy can have on caregivers and subsequently their care receivers. It is important
to explore their relationship with anxiety and depression amongst res and dom
caregivers due to the comparability in roles and responsibilities between, NHS staff,
MH workers and informal caregivers (Eustis et al., 1993).
Aims
Due to the increase in negative reports surrounding the poor organisational
support within res and dom services (for example, CQC, 2014; Franklin, 2014; Farooq,
2009; Koehler, 2014) that fail to meet the quality assurance standards proposed by
Eustis et al. (1993), known to impact on caregivers’ psychological well-being (for
example, Denton et al., 2002; Gray-Stanley et al., 2010), this research had three aims.
Firstly, to add to the small body of psychological well-being literature surrounding res
and dom caregivers (for example, Bartoldus, Gillery & Sturges, 1989; Colton &
Roberts, 2007; Denton et al., 2002; Hunter et al., 2012; Wibberley, 2013). The second
aim was to ascertain associations between caregivers’ perception of organisational
support and the possible impact on psychological well-being. Thirdly, that by redirecting
caregiver well-being research towards a psychological focus this study will

optimistically inspire future research to raise public, caring organisation and policy
makers awareness’ about the possible need to change caring organisations standards.
Hypotheses
Based on previous research, it was hypothesised that domiciliary caregivers will
experience greater levels of anxiety and depression than residential caregivers and the
control group due to slightly raised levels of turnover rates (Skills for Care, 2015),
negative impacts of irregular hours and the abundance of zero-hour contracts,
decreased time to care for care receives due to additional responsibilities, lower levels
of pay due to additional responsibilities like keeping the car on the road (Denton et al.,
2002; Franklin, 2014; Koehler, 2014; National Audit office, 2014; Wibberley, 2013) and
less benefits and pay than those working in an institutional setting (Crown et al., 1995).
Secondly it was hypothesised that low levels of internal LOC, low levels of
affective empathy, low levels of cognitive empathy, low levels of self-esteem and low
levels of POS will predict variance in anxiety and depression symptomology. All
variables were entered independently into the hierarchical multiple regression, in this
order, to ascertain their individual contribution over and above the other. However,
affective and cognitive empathy were entered together in the same step as research
has yet to define their individual contribution to anxiety and depression. POS was
entered after all of the variables to see if it had any affect above and beyond the other
psychological variables because of its assumed relatability to them. Occupation was
entered last into the regression to see if it had any overall affect above and beyond all
other variables.

Method
Participants
Caregiver data was collected from res and dom caregivers working in the North
West and the South of the UK currently caring for elderly adults, adults dementia,
adults with LD and adults with MH disabilities. Some care receivers were comorbid and
others also had a physical disability. Control group data was not regionalised but were
contacted through Facebook (FB), a social networking site, and university research
site. Total number of participants was 203 comprised of 51 dom caregivers, 85 res
caregivers and 67 non-caregivers. Ethnicity was not accounted for. Participation was
voluntary and participants were prior warned in the information sheet that if they
suffered from a pre-existing or present psychological condition, including depression
and anxiety, that taking part was at their own discretion (see Appendix 1, 2 and 3). Age
was restricted to eighteen and above. This was controlled for by sending a private
invitation to take part in the electronic copy of the questionnaire and was a stipulation
written in to the paper questionnaire.
Domiciliary caregiver demographic information. Of the 51 caregivers 5
(9.8%) were male, 43 (84.3%) were female and 3 (5.9%) were not disclosed.
Caregivers’ ages ranged from 19 to 77. The minimum and maximum length of time in
current caring position was 1 month and 39 years, respectively. The minimum and
maximum length of time working within the caring profession was 4 months and 39
years, respectively. The number of dom caregivers providing care for adults with LD
was 22, elderly was 34, dementia was 31, physical disabilities were 5 and MH was 1.
Physical disabilities and MH were comorbid with another social care requirement;
likewise participants caring form more than one care requirement was 32. The number
of dom caregivers employed full time were 25 (49%). With 17 (33%) working part time,
8 (15.7%) did not disclose. The number of dom caregivers working regular hours were
24 (47.1) with 16 (31.4%) working irregular hours, 11 (21.6%) did not disclose. The

number of domiciliary caregivers currently caring for a relative or close friend was 5
(9.8%), 37 (72.5%) did not and 9 (17.6%) did not disclose. Whilst 20 (39.2%) dom
caregivers had previously cared for a relative or close friend, 24 (47.1%) had not, 7
(13.7%) participants did not disclose. Of the 51 domiciliary caregivers 17 reported
being single, 27 reported being married/co-habiting, 5 were divorced/separated and 1
reported being a widow/er (see supplementary CD).
Residential caregiver demographic information. Of the 85 res caregivers 16
(18.8%) were male, 65 (76.5%) were female and 4 (4.7%) did not disclose. Ages
ranged from 19 to 71 and the minimum and maximum length of time in current caring
position was 1 month and 22 years, respectively. The minimum and maximum length
of time working within the caring profession was 3 months and 30 years, respectively
with a median average of 10 years. The number of participants caring for learning
disabilities was 68, elderly was 27, dementia was 27, physical disabilities were 10 and
mental health was 1. Physical disabilities and mental health were comorbid with
another social care requirement; likewise participants caring form more than one care
requirement was 36. The number of res participants in full-time employment was 63
(74.1). With 19 (22.4%) working part-time, 3 (3.5%) did not disclose. The number of res
caregivers working regular hours was 54 (63.5%). With 25 (29.4) working irregular
hours, 6 (7.1%) did not disclose. The number of res caregivers currently caring for a
relative or close friend was 10 (11.8%). Whilst 74 (87.1%) were not, 1 (1.2%) did not
disclose. Those previously cared for a relative or close friend was 31 (36.5%). Whilst
53 (62.4%) had not, 1 (1.2%) did not disclose. Of the 85 res caregivers 29 reported
being single, 48 reported being married/co-habiting, 6 were divorced/separated and 2
reported being a widow/er (see supplementary CD).
Control group demographic information. Of the 67 control participants 33
(49.3%) were male and 34 (50.7%) were female. Age ranged from 19 to 61.
Occupational type was not accounted for but 64 participants were students, 13 were in

employment, 12 of which were also students. Of the 67 control participants 24 were
single, 40 were married/co-habiting and 3 were divorced/separated (see supplementary
CD).
Ethical considerations
Prior to data collection this project was reviewed and passed by the University
of Chester, Psychology Department Research Ethics Committee, which conforms to
the ethical principles laid down by the British Psychological Society (see Appendix 4).
Additional amendment forms were sent for ethical approval relating to amendments to
the initial ethical approval for form (see Appendix 5) further amendments to study
including organisational consent to participate in research (see Appendix 6) and further
organisational consent to participate in the research (see Appendix 7, 8 and 9).
Measures
The hospital anxiety and depression scale (HADS). The HADS (Zigmond &
Snaith, 1983) is one of the most commonly used self-report questionnaires for the
study of anxiety and depression (DVs). It is a 4-point type Likert (0-3) type scale
consisting of 14 question divided evenly between the two factors (anxiety and
depression). HADS scoring assigns higher scores to indicate greater levels of anxiety
and depression. Scoring between 0 and 7 is considered normal, scoring between 8 and
10 is borderline abnormal and 11 and 21 is abnormal. An example of an anxiety
question was related to the whether an individual felt they had to be on the move due
to restlessness. Similarly, an example depression question was related to whether an
individual felt they had no need to maintain their appearance (Zigmond & Snaith,
1983). Prior research has demonstrated it to be robust in screening separate
dimensions of depression and anxiety in the general population, during general
practice and among psychiatric patients (Bjelland, Dahl, Haug & Neckelmann, 2002). It
has also construct and re-test validity with high internal subscale consistency and has
found to be reliable cross culturally (Reda, 2011). A high level of internal consistency of

the anxiety subscale α=.75 (see Appendix 10), depression subscale α=.76 (see
Appendix 11) and combined HADS α=.82 was duplicated using Cronbach’s alpha (see
Appendix 12).
The perceived organisational support (POS) scale. The eight item POS
scale was developed to be more user friendly (Rhoades, Eisenberger & Armeli, 2001)
from the original 40 items (Eisenberger, Huntington, Hutchinson & Sowa, 1986) so as
not to disinterested participants. As such it was designed to quantify POS in the work
place. The questionnaire is scored on a seven point Likert scale from 0 – 6 (strongly
disagree- strongly agree) with negative questions requiring reversing (2, 3, 5 and 7).
Rated on a scale from lowest to highest (more negative to a more positive response)
with an average of score of 24, higher scores are attributed to greater levels of POS.
“The organization would ignore a complaint from me” (Eisenberger et al., 1986, p. 502),
is an example question from the questionnaire. Whilst “the SPOS measures with high
reliability” (Rhoades & Eisenberger, 2002, p. 699), to diversify between subject groups
the seventeen highest factor loading items from the original 40 appear to be the most
prevalent in POS studies (for example, Cleveland & Shore, 1992; Randall & O’Driscoll,
1997). As such the use of the 8 question version appears not to be problematic and is
still reflective of the well-being of the organisations employees (Rhoades &
Eisenberger, 2002). Cronbach’s alpha scores were calculated at α=.90 (see Appendix
13) indicating a high level of internal consistency.
The locus of control (LOC) scale. LOC is a scale designed to measure the
“the extent to which one regards one’s life chances as being under one’s control in
contrast to being fatalistically ruled” (Pearlin & Scholer, 1978, p. 5). “There is little I can
do change many of the important things in my life” (Pearlin & Scholer, 1978, p. 20) is
an example of a question from this scale. The self-report questionnaire consists of 7
items scored on a 4 point Likert scale from 1-4 (strongly agree – strongly disagree).
Positive questions (6 and 7) are reverse scored. Rated on a scale from lowest to

highest (more negative to a more positive response) with an average scored between
17 and 18 higher scores are related to a greater LOC. Developed for working adults
between the age of 18 and 65, researchers have used it in other populations including
adolescents and with mental health difficulties as well as being translated into
numerous languages (Brady, 2003). Cronbach’s alpha scores were calculated at α=.82
(see Appendix 14) indicating a high level of internal consistency.
The basic empathy scale (BES). The BES is a two factor 20 item scale
developed by Jolliffe and Farrington (2006) to measure empathy from two subscale
factors (affective empathy and cognitive empathy). “I get caught up in other people’s
feelings easily” (Jolliffe & Farrington, 2006, p. 593) is an example of an affective
question, ‘‘It is hard for me to understand when my friends are sad’’ (Jolliffe &
Farrington, 2006, p. 593) is an example of a cognitive question. Both affective and
cognitive states are essential to emotional functioning requiring the recognition of other
people’s feelings as well as their own. The affective empathy subscale is comprised of
11 items scored on a 5 point Likert scale from 1-5 (strongly disagree-strongly agree)
with an average score of 33. The cognitive empathy subscale is comprised of 9 items
scored on a 5 point Likert scale from 1-5 (strongly disagree-strongly agree) with an
average of 23. Below average scores are attributed to having less affective/cognitive
empathy and above average scores are attributed to having high levels of
affective/cognitive empathy. Included were 8 reverse scored items (1, 6, 7, 8, 13, 18,
19 and 20). Whilst the BES had been specifically designed for adolescents and has
now been adapted for adults (BES-A) showing some promising reliability (Carré et al.,
2013), the original BES was still chosen for this research. This decision was related to
the vast amount of positive attention it has received including satisfactory internal
consistency and moderate retest reliability also it has shown to be valid cross culturally
(D’Ambrosio et al., 2009; Geng et al., 2012; Sánchez-Pérez, Fuentes, Jolliffe &
González-Salinas, 2014).

Consent of BES
Consent was obtained from the authors prior to its implementation (see
Appendix 15). A moderate level of internal consistency of the affective empathy
subscale α=.72 (see Appendix 16), cognitive empathy subscale α=.74 (Appendix 17)
and combined BES α=.77 was found using Cronbach’s alpha (Appendix 18).
The Rosenberg self-esteem scale (RSES). The RSES (Rosenberg, 1965) is
one of the most widely used measures of self-esteem, popular for its succinctness (10
items) and its uncomplicated language “I take a positive attitude towards myself”
(Rosenberg, 1965, cited in Harvey & Keashly, 2003, p. 810). The RES is scored on a 4
point Likert scale 1-4 (strongly disagree-strongly agree) with an average of 25. Higher
scores correspond to greater levels of self-esteem with 5 items require reverse scoring.
Reliability and validity for the scale has been assumed among a number of groups
including nursing assistants (McMullen & Resnik, 2013). It is also seen to be stable
over time (Marsh, Scalas & Nagengast, 2010) and valid cross culturally (Meurer, Luft,
Benedetti & Mazo, 2012). Cronbach’s alpha scores were calculated at α=.87 (appendix
19) indicating a high level of internal consistency.
Materials
Three questionnaires were designed: a paper copy for res and dom caregivers
(see Appendix 20), a digital copy for the FB (see Appendix 21) control group and a
second digital copy for the SONA control group (see Appendix 22). A mixture of paper
and digital copies were used to access a wider breadth of participants. The outlay of
the questionnaire information changed from the proposed design for ease of use and to
cut down on pages so as not to make it appear too daunting for the participants. All
three questionnaires contained an information page (see Appendix 1, 2 and 3),
demographics page (see Appendix 23, 24 and 25), the POS questionnaire (see
Appendix 26), LOC questionnaire (see Appendix 27), BES questionnaire (see
Appendix 28), RSES questionnaire (see Appendix 29), HADS questionnaire (see

Appendix 30) and a debrief page (see Appendix 31, 32 and 33). Participation was
voluntary. The paper copy contained a separate consent form requiring a signature and
date (see Appendix 34). Consent from the SONA group was obtained via clicking a box
at the bottom of the information page (see Appendix 3) whereas consent from the FB
group was assumed post questionnaire submission (see Appendix 2).
Whilst there were subtle differences between all three questionnaires’
demographic pages because of the different target population samples, both the FB
and SONA questionnaires were not exclusive to non-caregivers (see Appendix 24 and
25. Both digital demographics pages contained a question relating to caregiver
employment status (see Appendix 24 and 25). This option was made available to
obtain as many caregiver responses as possible. There were also subtle content
differences within the information sheet content due to the participant type. For
example, the SONA group’s information page was written for the perspective of
psychology student thus the language and presentation of content would appeal to
their academic nature (see Appendix 3). Also, unlike the other groups an incentive of
two credits (an accumulation of 10 credits enables the student to use the SONA system
for their own research purposes) was awarded for participation indicated in the
information sheet (see Appendix 3). However all information sheets contained details of
the research, its intent, anonymity, instruction, ethical consent, dissemination and
contact details (see Appendix 1, 2 and 3).
There were also subtle differences between groups in the debrief page. This
concerned the practicality of returning the questionnaires. Whereas the paper copies
were to be handed back to an assigned staff liaison or manager charged with the role
of distribution and collection (see Appendix 31), the digital copies contained a
submission button which automatically uploaded the content on to a formic system
(software that collates digital information and stores it on a central database) (see
Appendix 32 and 33).

Procedure
Accesses to caregiver participants were sought through a series of phone calls
and emails directly to the organisational manager. Prior to the distribution of
questionnaires an email of consent was required from the organisational managers
(see Appendix 35). In some cases, face to face meetings were setup. Printed
questionnaires (see Appendix 20) were handed directly to the organisational manager
or to an arranged staff liaison to distribute amongst their care staff. All completed,
withdrawn or incomplete questionnaires were handed back to the liaison/organisational
manager and locked away safely until collected by the researcher. Raw data was
extrapolated form the paper questionnaires by a process of digital scanning. This data
was stored in a central database accessible only to University psychology technicians
or on request by the researcher. Simultaneously, control group participation was
sought through a private message via the researcher’s private FB account. The
message contained a hyperlink to the questionnaire (see Appendix 21). SONA
participants were not directly contacted. Details of the research were posted on the
University’s SONA page, only accessible to University SONA users (psychology
students and staff) (see Appendix 22). Questionnaire participation was voluntary.
Raw data from both digital questionnaires was transferred to the same
database along with the paper copy data after submission. Data collection lasted
approximately two and a half months. Consent forms were immediately separated from
the questionnaires, if not already done so by the participants, and stored separately in
a lockable filing cabinet. Once data had been extrapolated from the paper copy
questionnaires they were locked away in the same cabinet as the consent forms. There
were no identifiable markers to match corresponding consent forms and
questionnaires. Raw paper, SONA and FB questionnaire data was transferred into an
SPSS spreadsheet and emailed to the researcher after data collection had concluded
(see supplementary CD). This was then stored on an encrypted and password

protected USB stick. Due to technical issues following the shutting down of the formic
system with two weeks still remaining of the data collection period, the researcher input
data manually from questionnaires returned within this time period. Missing data points
in the paper copy SPSS spreadsheet was input manually from the original
questionnaires then data from all three spreadsheets were input into one SPSS spread
sheet (see supplementary CD).
Reverse scoring of appropriate questions were undertaken as was the division
of HADS and BES into their two subscales. Means scores were calculated and input
into a new SPSS data sheet with the demographic data (see supplementary CD). Data
analysis followed. Following research submission, a condensed version of the findings
was shared with the consented organisations that took part. This was within the interest
of communication and data sharing. The findings will enable the organisations to reflect
on their own practice. All organisations were made aware that this is a summation data
from all consented organisations that individually cannot be made identifiable.
Methodological issues
Initial analysis of the two factor empathy scale found the mean scores to be
abnormally low. This was attributed to the direction of the Likert scale which was
reversed on the questionnaire (See Appendix 28). All empathy scores were reversed in
the SPSS data sheet and means were recalculated. For replication of study Likert
scoring direction of the BES will need to be revised. Whilst non caregiver respondents
had the opportunity to fill out the questionnaires as a dom or res caregiver, the section
indicating what type of individual do they care for (for example, Elderly and dementia)
was not available (See Appendix 24 and 25). Furthermore, because the question
relating to what type of individual do you care for was a multiple choice option. A
number of respondents had ticked more than one option due to comorbidity of
disabilities. The scanning system that inputs the data into the formic system that
collates onto SPSS could not distinguish between options (See Appendix 23). A better

method would have been to number the options or to have had a comorbid option to
prevent data being input by hand.
Design and analysis
A between-subjects, cross sectional design was used to compare two subject
groups, who were domiciliary caregivers and residential caregivers. A third non-
caregiver subject group (control) was also used as a baseline to compare caregiver
findings against.
Initially descriptives were run to find out the minimum, maximum and mean
scores from all scales within the questionnaire from each group (see Appendix.36, 37
and 38). A one way between subjects ANOVA was carried out to determine whether
there were any significant differences between the scale means (see Appendix 39) with
Tukey’s post hoc analysis to specify the statistically significant difference between the
groups (see Appendix 40). Only significant Tukey post hoc scores were reported.
Cronbach’s Alpha test was conducted onto measure the internal consistency
with participants’ HADS scores (see Appendix 10, 11 and 12), POS scores (see
Appendix 13), LOC scores (see Appendix 14), BES scores (see Appendix 16, 17 and
18) and RSES scores (see Appendix 19).
Pearson correlation test of all psychological variables was carried out (see
Appendix 41). Demographics and characteristics were excluded. For parsimonious
reasons only the variables that were significantly associated with the anxiety and
depression were put forward as predictor variables in hierarchical multiple regression
analyses. The enter method was used because this was an exploratory study wanting
to find the exact contribution of each variable to anxiety (see Appendix 42) and
depression (see Appendix 43). High comorbidity of anxiety and depression led to the
exclusion of these variables as predictors. POS was the last psychological predictor
entered into the multiple hierarchical regression analyses to examine its individual
contribution to predicting anxiety and depression over and above the other variables

because of its assumed relationship with them. Occupation type was the last variable
entered into the model to ascertain to what extent a caregiving or non-caregiving role
predicted anxiety and depression symptomology within this sample. A dom caregiver
was scored with a 1, a res caregiver was scored with a 2 and the control were scored
with a 3 (see supplementary cd). Alpha levels were set at 0.05.
Results
Analyses focused on participants’ anxiety, depression, POS, LOC, affective
empathy, cognitive empathy and self-esteem levels. Initially, descriptive analysis was
calculated including means, standard deviations of all psychological variables (see
table 1). One way analyses of variance were undertaken to ascertain if there was any
statistical difference between group scores (see table 1) with Tukey’s post hoc analysis
used to identify the statistical difference between which of the groups. Post hoc
analysis was only performed where ANOVAs were found to be statistically significant.
Thirdly, correlation analysis was performed to ascertain statistically significant
associations between variables (see table 2). Finally, enter hierarchical multiple
regression analyses were conducted to ascertain which entered variables would
statistically predict anxiety and depression symptomology (see table 3 and 4). Anxiety
and depression were omitted from the analysis when predicting each other. Cognitive
and affective empathy were entered together into the same step apart from in the
hierarchical multiple regression to predict anxiety. Only statistically associated
variables found in the correlations analysis were entered into the regression analysis.
Inferential tests
Depression scores for all three groups were under the threshold for sub clinical
depression. Table 1 shows that control group had the lowest scores for depressive
symptomology, whilst the dom group had the highest with the res group scoring
between the two. A one way ANOVA found there was a significant difference, with
Tukey’s post hoc analysis confirming that it was between the higher depression scores

of the dom group and the lower depression scores of the control group (p = .01). Table
1 shows that the res group had the highest mean scores for anxiety symptomology and
the control group had the lowest with dom group scoring between the two. The res
group mean score was just below the threshold for borderline anxiety, while both dom
and control groups mean scores were within normal range. A one way ANOVA found
there to be no significant differences between scores.
All three POS mean scores were within the higher range of the POS scale over
the central point (above 24). Table 1 shows that dom caregivers had the highest scores
for positive POS, whilst the control group had the lowest with the res group scoring
between the two. A one way ANOVA found there to be no significant differences
between scores.
All three internal LOC mean scores were within the higher range of the LOC scale over
the central point (above 17.5). Table 1 shows that the control group experienced a
greater loss of control compared to dom group who experience less loss of control with
residential scoring between the two. A one way ANOVA found there to be no
significance between the scores.
All three mean group affective empathy scores were just within the higher range
of the BES over the central point (above 35). Table 1 shows that the control group had
the highest scores for affective empathy, whilst the dom group scored the lowest for
affective empathy with the res group scoring between the two. A one way ANOVA
found there to be no significance between scores.
Similarly, all three mean group cognitive empathy scores were within the higher
range of the BES over the central point (above 27). Table 1 shows that the control
group obtained the highest mean scores for cognitive empathy symptomology, whilst
the res group scored the lowest with the dom group was scoring between the two. A

Table 1
Descriptives and one way ANOVA scores of the HADS, POS, LOC, basic empathy and self-esteem scales undertaken by dom caregivers,
res caregivers and control the control group.
Variable Caregiver
type
Mean
(M)
Stranded
deviation
(SD)
Min/max
scored
Min/max
possible
One way ANOVA
Depression: Domiciliary 4.49 3.55 0/13 0/21
Residential 3.42 2.83 0/17
Control 2.85 2.29 0/10 F(2, 200) = 4.767, p = .01
Anxiety: Domiciliary 6.78 3.16 0/16 0/21
Residential 7.02 3.35 1/16
Control 6.76 3.28 0/16 F(2, 200) = .147, p = .86
Perceived
organisational
support: Domiciliary 34.98 12.94 6/48 0/48
Residential 34.65 10.89 9/48
Control 31.21 8.89 9/45 F(2, 200) = 2.434, p = .09
Locus of control: Domiciliary 22.73 3.82 14/28 7/28
Residential 22.19 3.47 14/29
Control 21.88 3.83 7/28 F(2, 200) = .768, p = .47
Empathy affective: Domiciliary 36.69 4.55 26/48 11/55
Residential 38.29 6.27 21/51
Control 38.58 5.29 27/48 F(2, 200) = 1.909, p = .15
Empathy cognitive: Domiciliary 35.65 3.35 27/43 9/45
Residential 35.29 4.46 24/45
Control 36.94 3.64 26/45 F(2, 200) = 3.439, p = .03
Self-esteem: Domiciliary 31.31 4.72 21/40 10/40
Residential 29.68 5.78 19/40
Control 31.43 5.16 20/40 F(2, 200) = 2.518, p = .08

one way ANOVA found there to be a significant difference between the scores, with Tukey’s
post hoc analysis confirming that the moderate significant difference was between the higher
control group scores and the lower res group scores (p = .03).
All three mean self-esteem empathy scores were within the higher range of the
RSES over the central point (above 25). Table 1 shows that the control group had the
highest mean scores for self-esteem, while res group scored the lowest with the dom group
scoring between the two. A one way ANOVA found there was no significance between
scores.
Pearson’s correlation test. Pearson’s correlation was used to examine associations
between all variables within the study (see table 2). Table 2 indicates that there was a strong
statistically significant positive association between depression and anxiety. Furthermore,
depression was found to have a strong statistically significant association between low levels
of POS and low levels of internal LOC. Depression also had a moderate yet statistically
significant association with low levels of affective empathy, low levels of cognitive empathy
and low levels of self-esteem. Table 2 indicates that there was a strong statistically
significant association between anxiety and low levels of internal LOC. Furthermore, anxiety
was also shown to have a moderate though statistically significant association with low
levels of self-esteem and a moderately statistically significant positive association with
affective empathy.
Table 2 indicates a strong statistical significant positive association between POS
and internal LOC. Equally, there was a strong statistically significant positive association
between cognitive empathy and internal LOC and between self-esteem with internal LOC.
Also, there was a strong statistically significant positive association between cognitive
empathy and affective empathy. All variables statistically associated with anxiety and
depression was suitably reliable for examination through hierarchical regression (see tables
3 and 4).
Table 2

Bivariate association between groups (dom caregivers, res caregivers and control group)
and HADS, POS, LOC, basic empathy and self-esteem scores
1 2 3 4 5 6 7
1 Depression 1
2 Anxiety .45** 1
3 Perceived
organisational support
-.22** -.12 1
4 Locus of control -.37** -.31** .42** 1
5 Affective empathy -.15* .15* -.03 .00 1
6 Cognitive empathy -.16* .02 .04 .22** .35** 1
7 Self-esteem -.15* -.14* .02 .26** -.02 .10 1
**p < .01; *p < .05
Hierarchical multiple regression predicting Anxiety. Internal LOC variable was
entered into the first step of the hierarchical multiple regression analysis. As such, low levels
of internal LOC was found to be statistically significant explaining for 9.3% of variance in
anxiety symptomology adjusted to 9% (see table 3). Higher levels of affective empathy
increased the predictive power of this model explaining a total of 11.7% adjusted to 11%.
However, whilst higher levels of affective empathy were found to be a uniquely statistically
significant contributor, its predictive capability is weak. In step three, low levels of self-
esteem faintly increased the predictive power of the entire model explaining 11.9% of anxiety
symptomology. However, its individual contribution was not statistically significant over and
above the other variables and its influence actually decreased the predictive capability of the
model at this point, adjusted to 11%. After entry of occupation at step four the total variance
explained by the model increased to 12.2%. However, its individual contribution was not
statistically significant and decreased the predictive power of the overall model, adjusted to
10%. Low levels of internal LOC and higher levels of affective empathy remained statistically
significant and marginally stable throughout all steps of the analysis. Furthermore, they were
the only two variables that made a statistically significant contribution towards anxiety
symptomology over and above low levels of self-esteem and occupation type. However, the
unique contribution made by low levels of affective empathy was weak.

Table 3
Summary of hierarchical multiple regression analysis for variables predicting anxiety
Anxiety
R-sq
adj.)
F (p-value) β (p-value)
Step 1
Locus of control
.09 20.684 (p<.001)
-.305 (p<.001)
Step 2
Locus of control
Affective empathy
.11 13.214 (p<.02)
-.306 (p<.001)
.154 (p<.02)
Step 3
Locus of control
Affective empathy
Self-esteem
.11 9.081 (p<.47)
-.293 (p<.001)
.148 (p<.03)
-.050 (p<.47)
Step 4
Locus of control
Affective empathy
Self-esteem
Occupation
.10 6.857 (p<.46)
-.298 (p<.001)
.155 (p<.02)
-.047 (p<.50)
-.050 (p<.46)
Hierarchical multiple regression predicting depression. Internal LOC variable
was entered into the first step of the hierarchical multiple regression analysis and was shown
to be a statistically significant contributor explaining 13.3% of variance in depression
symptomology adjusted to 13% (see table 4). Low levels of affective empathy and low levels
of cognitive empathy marginally increased the predictive power of the model at step two
explaining 15.6% of the variance on predicting depression symptomology, adjusted to
14.4%. However only lower levels of affective empathy were found to be statistically
significant (see table 4). Low levels of self-esteem marginally increased the predictive power
of the model at step 3 explaining a 16.2% of the variance of depression symptomology
adjusted 14.5%. However, its individual contribution was not found to be statistically
significant above and beyond all other variables at this step. Low levels of POS marginally
increased the predictive power of the model at step 4 explaining 16.9% of the variance of
depression symptomology adjusted to 14.8%. After entry of occupation type at step five the
total variance explained by the model was 22.2% adjusted to19.8%. The individual
contribution of occupation type was found to be a statistically significant contributor in

explaining depression symptomology over and above all other variables. The occupation
type was the domiciliary group.
Table 4
Summary of hierarchical multiple regression analysis for variables predicting depression
Depression
R-sq
adj.)
F (p-value) β (p-value)
Step 1
Locus of control
.13 30.874 (p<.001)
-.365 (p<.001)
Step 2
Locus of control
Affective empathy
Cognitive empathy
.14 12.289 (p<.07)
-.356 (p<.001)
-.135 (p<.05)
-.037 (p<.61)
Step 3
Locus of control
Affective empathy
Cognitive empathy
Self-esteem
.15 9.544 (p<.26)
-.338 (p<.001)
-.146 (p<.04)
-.030 (p<.68)
-.076 (p<.26)
Step 4
Locus of control
Affective empathy
Cognitive empathy
Self-esteem
Perceived organisational
support
.15 8.032 (p<.18)
-.295
(p<.001)
-.148 (p<.04)
-.033 (p<.64)
-.085 (p<.21)
-.097 (p<.18)
Step 5
Locus of control
Affective empathy
Cognitive empathy
Self-esteem
Perceived organisational
support
Occupation
.20 9.306 p<.001)
-.313
(p<.001)
-.129 (p<.06)
-.004 (p<.95)
-.076 (p<.25)
-.123 (p<.08)
-.235
(p<.001)
Whilst low levels of internal LOC marginally decreased as a unique predictor of depression
symptomology throughout each step of the analysis, it remained statistically significant.
Contrarily, the unique contribution of low levels of affective empathy marginally increased
throughout each step of the analysis until occupation was entered at the final stage when its
contribution became statistically insignificant. Only low levels of LOC and occupation type
were found to be strong statistically significant individual contributors towards explaining
depression symptomology within this sample. Whilst low levels of affective empathy were
significant until the final stage of the model, its significance was weak. The contribution of

low levels of cognitive empathy decreased throughout each step of the analysis.
Furthermore, the contribution of low levels of POS in explaining depressive symptomology
increased in the final stage of the analysis. However, it remained statistically insignificant
(see table 4).
Discussion
Reminder of aims and hypotheses
Based on recent reports surrounding the state of domiciliary and residential care in
the UK (for example, CQC, 2014; Franklin, 2014; Farooq, 2009; Koehler, 2014) and prior
well-being research (for example, Denton et al., 2002; Gray-Stanley et al., 2010) it was
hypothesised that dom and res caregivers would be more susceptible to anxiety and
depression symptomology than non-caregivers. However, that dom caregivers would be
more susceptible to anxiety and depression than res caregivers. It was further hypothesised
that low levels of internal LOC, low levels of affective empathy, low levels of cognitive
empathy, low levels of self-esteem and low levels of POS would predict anxiety and
depression symptomology. The results lent some strong support for the first hypothesis.
However, they showed less support for the second hypothesis.
Discussion of results and hypotheses
In line with the first hypothesis comparisons between mean HADS scores found that
both caregiver groups had higher anxiety and depression scores than the non-caregiver
groups. This result is consistent with prior research indicating that caregivers are more
susceptible to poorer MH than non-caregivers (Butterworth et al., 2010). Whilst dom
depression scores were higher than res and the control, post hoc analysis indicated that only
between dom and control group scores were statistically significant suggesting that res and
dom caregivers, within this sample, are similarly susceptible to depression symptomology.
However, results from the hierarchical analysis indicated that depression symptomology is
strongly attributed to working as a dom caregiver. Yet, this result should be viewed with

caution as all three mean depression scores were within normal depression range, thus not
clinically recognised for immediate intervention.
Contrary to the anxiety hypothesis, ANOVA yielded no significant differences
between all three groups’ mean anxiety scores. Also, occupation type was not found to be a
significant predictor of anxiety in the final step of the regression analysis. This suggests
anxiety symptomology is not necessarily attributed to working as a dom or res caregiver
compared to a non-caregiving role. Additionally, res caregiver mean anxiety scores were
higher than dom caregiver scores, just below the threshold for borderline anxiety. Whilst this
result conflicts with the hypothesis, it offers some moderate support for prior research
indicating that res caregivers are likely to experience anxiety (Mutkins et al., 2011). Yet,
these findings were used to interpret anxiety and depression’s relationship to emotional
exhaustion and depersonalisation for which only depression was found to be a significant
predictor.
In line with the second hypothesis, low levels of internal LOC were found to have a
statistically significant contribution to anxiety and depression over and above the other
psychological variables. This result supports prior research that higher levels of internal LOC
are related to better quality of life and fewer depressive symptoms (Gibson et al., 2013) and
provides evidence to the contrary of the belief that only external LOC predicts anxiety (for
example, Molinari & Khanna, 1981) and depression (Presson & Benassi, 1996). Whilst the
review of literature yielded no previous association between empathy and depression, low
levels of affective empathy were found to be a moderate predictor of depressive
symptomology above and beyond low levels of all other psychological variables. However, in
the final step of the hierarchical multiple regression analysis, low levels of affective empathy
was no longer found to be statistically significant suggesting that occupation was a much
greater predictor.
In contradiction to the hypothesis, higher levels of affective empathy were found to be
a moderate predictor of anxiety symptomology. This remained relatively stable throughout
each step of the analysis, suggesting that it has a greater contribution to anxiety

symptomology over all other psychological variables, apart from low levels of LOC. However,
whilst it was posited that there may be a relationship between empathy and anxiety, even
though a systematic review of literature yielded no direct association, the direction of this
result was unexpected. According to Austin et al., (2009) the ability to empathise would
decrease if a caregiver was subject to decrease in well-being. However, this was assumed
to be in relation to stress, burnout and emotional contagion not anxiety. As such this result
should be viewed with caution considering that the predictive power of high levels of
affective empathy on anxiety was only moderate.
Res and dom type characteristics reflects both national and past research caregiver
characteristics. Specifically, the disproportion of female to male employees, average age,
employment type and type of working hours (Crown et al., 1995; Skills for Care, 2015;
Zeytinoglu, et al., 2009), validating comparison to past caregiver research.
Discussion of POS variable. No other psychological variables were found to
contribute towards anxiety and depressive symptomology. Non-caregivers recorded higher
mean POS questionnaire scores than both caregiver groups. Furthermore, analysis of
variance reported no significant difference between group mean scores, suggesting that
caregivers feel equally valued by their organisation than non-caregivers. This sample then
conflicts with the accounts from recent UK reports (for example, CQC, 2014; Franklin, 2014;
Koehler, 2014) that caregivers, particularly dom caregivers, are operationally, financially and
socially unsupported by their organisations.
POS had no significant correlation relationship with any of the psychological
variables apart from its positive association with internal LOC and a negative association
with depression. As covered, it was not found to be a significant predictor of depression
symptomology. Whilst this is contrary to previous findings that an employee with low POS
will generally suffer from anxiety symptomology (Rhoades & Eisenberg, 2002), it suggests
that this sample’s well-being may not be affected by negative organisational cultures as seen
in prior caregiver research (Denton et al., 2002). This may be inferred by the quality of
organisations that participated in the questionnaire who in turn may support and value their

employees. The plausibility of this interpretation is related to the poor response rates from
organisations willing to participate. Those who consented may already recognise their
contribution towards protecting their employees’ well-being, subsequently reflecting those
outstanding services recognised in the Care Quality Commission report (2014).
Discussion of self-esteem variable. No statistical differences were found between
groups RSES scores even though res caregivers recorded lower mean scores compared to
dom and res caregivers. This suggests that the role of caregiving may not contribute to lower
levels of self-esteem when compared to non-caregivers. Results of the correlation analysis
contribute to the literature associating low self-esteem with feeling anxious (Lee & Hankin,
2009; Riketta, 2004) and depressed (Riketta, 2004; Sowislo, et al., 2014; Sowislo et al.,
2014; Zunzunegui et al., 2002). However, correlations were found to be weak and did not
statistically predict anxiety and depression symptomology. A professional perspective could
suggest that caregivers socioemotional need from their organisations are met, proposed by
POS theory (Rhoades & Eisenberg, 2002). If the caregivers’ self-esteem is dependent on the
amount of organisational support then this may clarify its lack of accountability in explaining
depression and anxiety symptomology. As such, this may suggest that the recommendations
by the Burnstow report to improve self-esteem amongst caregiver (for example, greater
training, free influenza vaccinations and key-worker status) are already enforced within these
participated organisations (Koehler, 2014). However, the correlation analysis failed to show
a statistical association between POS and self-esteem.
Caregiver, self-esteem scores could be related to job satisfaction. In particular the
positive aspects of caregiving through maintaining healthy mutual relationships with care
receivers’ (Kramer, 1997; Lopez et al., 2005; Neufeld & Harrison, 1995). Potentially by
having adequate time to provide care and by using effective coping strategies to deal with
the potential challenging behaviours that provoke stress (Denton et al., 2002 ) known to
impact on self-esteem (Orth et al., 2009). This is inferred from the high proportion reported
care receivers that are either elderly, comorbid and or have dementia. These are both
associated with challenging behaviours (for example, Molyneux, et al., 2008; Rose et al.,

2013). However, the findings do not support this assumption. It is merely a postulation. As
such, self-esteem like mood and happiness fluctuates (Campbell et al., 1991; Galambos et
al., 2015) thus the differences in scores may be related to how the participants felt during the
questionnaire completion as a consequence of external life events or even the time of day.
Discussion of affective and cognitive empathy variables. Both affective and
cognitive BES mean scores were within a similar range suggesting that caregivers and non-
caregivers are equally capable at recognising other people’s emotions and mental states as
well as their own (Carré et al., 2013; Jolliffe & Farrington, 2006). Correlation analysis
confirmed their positive relatability in line with the development and validation of the scale
(Jolliffe & Farrington, 2006). Whilst between group affective empathy scores yielded no
significant difference, post hoc analysis found a moderate statistical difference between dom
caregiver and control mean cognitive scores in favour of control. Contextually, this result
conflicts with the assumptions that caregivers may be more adapt to feelings of empathy, a
prerequisite for providing compassionate care for vulnerable adults (Globe et al., 2009;
Koehler, 2014). Similarly, the disproportion in female participants between the caregiver
groups (84.3%, 76.5%) and non-caregiver group (50.7%) conflicts with Joliffe and
Farrington’s (2006) findings that females had higher affective and cognitive empathy scores
than males and that females were more likely to respond prosocially to an individual’s
distress. However, this was not related to a caregiving context. This result could be
interpreted as compassion fatigue known to impact on empathy triggered by stress and
burnout as found in nurses (Austin et al., 2009). However, correlation results found no
negative association between affective and cognitive empathy and other variables apart from
a moderate association between affective empathy and depression. This suggests if the lack
of difference in empathy scores between caregiver and non-caregiver groups is attributable
to a psychological impact, then POS, LOC, self-esteem and anxiety are not one them,
according to these findings. Thus, additional research is required to quantify this assumption
using other variables such as stress and burnout.

A lack of statistical difference between caregiver and non-caregiver mean empathy
scores may be attributable to the appropriateness of the scale. Designed for adolescents,
contextually it is not designed for the work place. Therefore questions including ‘‘It is hard for
me to understand when my friends are sad’’ (Jolliffe & Farrington, 2006, p. 593), may not be
contextually relevant as caregivers may be able to differentiate how they control or interpret
their emotions between a friend who maybe in distress compared to a care receiver who is in
distress. To quantify this assumption a replication study may use the BES-A (Carré, 2013).
Whilst questions including “Other people’s feelings don’t bother me at all” (Carré, 2013, p.
690) are not directly related to an occupational setting they are more generic thus may give
a truer representation of empathy between a caregiver and non-caregiver.
Discussion of LOC variable. LOC results show that caregivers scored higher than
the non-caregiver group. Yet, no statistical difference between LOC means scores were
found, suggesting that there is no remarkable difference in how caregivers and non-
caregivers within this sample perceive themselves to be in control of their own life events. All
scores were in the higher range of the scale suggesting that all groups have above average
internal LOC in relation to the numerical scoring of the scale. Also, correlation analysis found
a statistically significant positive association between LOC and POS. This conflicts with the
assumption that caregivers maybe more susceptible to lower levels of internal LOC than
non-caregivers inferred from the lack of social, financial and operational support for
caregiver , particularly dom caregiver, in the workplace (for example, CQC, 2014; Denton et
al., 2002; Franklin, 2014; Koehler, 2014). As such, POS theory indicates that feeling valued
as an employee is related to aspects of social support in the workplace (Rhoades &
Eisenberg, 2002) not just operational support. Thus the positive association between POS
and LOC may have been mediated by aspects of social support from the organisation. The
plausibility of this assumption reflects the research by Lefcourt et al. (1984) who believed
that being socially supported can lead to positive coping strategies for those with an internal
LOC that in turn deter depressive symptomology (Chan, 2000). This interpretation reflects
the negative association between internal LOC and POS as an outcome of the correlation

analysis mirroring the belief that a lack of social support is related to depressive
symptomology (Rodakowski et al., 2012) in a caregiving capacity. However this was in
relation ageing adults with spinal cord injuries cared for by paid family members. Similarly,
correlation analysis revealed a strong positive association between internal LOC and self-
esteem. This association is consistent with prior research indicating that high internal LOC is
related to coping strategies that manage not just self-esteem (Anderson, 1998) but stress
(Hay & Diehl, 2010) and psychological adjustment (Elfstöm & Kreuter, 2006) in non-
caregivers and in the caregiving context also (Pelletier et al., 1994).
Limitations
A number of limitations of the current research should be noted, including the small
sample sizes, which appear problematic in caregiver research (Mutkins et al., 2011). Of all
three groups dom caregivers had the poorest response rate. This was in part due to the
nomadic nature of the work. It was communicated from dom care managers that caregiver
visits to the office were brief and infrequent impacting on the ability of managers to distribute
and collect the questionnaires. Furthermore, a large number of dom care organisations were
retendering for contracts during the data collection period. This further impacted on
questionnaire response rate as dom caregivers were moving companies for fear of job
losses if contracts were not secured. In one instance, a consented dom care organisation
disbanded prior to questionnaire distribution. Similarly, participant response rates between
organisations were extremely varied, impacting on an accurate measurement of the
variables. This was interpreted by the sensitive and personal nature of the questions and the
length of the questionnaire during feedback. However, inconsistent response rates are seen
to be a common occurrence within caregiver samples (Gray-Stanley et al., 2010).
Furthermore, whilst questionnaire feedback was taken from two regions it is not nationally
representative thus the results must be interpreted with some caution.
Future research
A complete replication of this study would require a larger sample size from all three
groups. This would preferably be a national sample thus requiring a longer period for data

collection. Furthermore, an incentive might be used to entice participation from those less
forthcoming organisations. However, if this research reflected the lack of statistical
difference between caregivers and non-caregiver group scores found by this study, then
perhaps using different well-being measures would be more appropriate. For example,
subjective burden and dysfunctional coping are seen to be related to anxiety (del‐Pino‐
Casado et al, 2014). Similarly, challenging behaviour and cognitive functioning of elderly
dementia care receivers are known to have had a direct impact on depression levels
(Molyneux et al., 2008). However these are hard to qualify as individual predictors of anxiety
and depression because of their relatability to other psychological variables recognised as
umbrella terms including burnout and ‘work stress’, which have seen to be related to
depression (Gray-Stanley et al., 2010).
Whilst this was an explorative study, future research may endeavour to differentiate
between the impacts natural stressors related to the caring role have on anxiety and
depression and the related significance that poor organisational support has on anxiety and
depression as a means to provide the correct interventions. One method adopted by Denton
et al. (2002) was the use of focus groups. By gathering specific information on the
caregiver’s perceptions of their work environment they were able to develop a self-
administrative questionnaire in conjunction with findings from a literature review. Caregivers
MH and well-being were then measured by three independent variables (job satisfaction,
stress and job stress) by ordering focus group outcomes (for example, working conditions)
and coding questions into Likert point scales. As such, Denton et al. (2002) were able to
pinpoint working characteristics of the caregiving role towards well-being measures. For
example, job-related stress was related to excessive workload and difficult clients. This
approach would enable this current research to pin point with greater accuracy the negative
perceptions of working for an organisation with specific practices that may lead to anxiety
and depression symptomology. Findings dependent, this research will be able to make
specific recommendations to organisations as a means for positive interventions.
Conclusion

This research was aimed to quantify and compare res and dom caregiver’s
susceptibility to anxiety and depression compared with a non-caregiver group and to
ascertain what extent anxiety and depression were predicted by low levels of LOC, low
levels of POS, low levels of self-esteem, low levels of affective empathy and low levels of
cognitive empathy. This research has shown moderate support for the attribution of anxiety
and depressive symptomology in res and dom caregivers compared to non-caregivers within
this sample. Whilst the role of a dom caregiver was shown to be a statistically significant
predictor of depression, the role of a res caregiver did not. This partially supports the first
hypothesis. Furthermore, results suggest that whilst a res caregiver is most likely to
experience anxiety symptomology when compared to a dom caregiver role and to the non-
caregiver group, res caregiving occupation type did not statistically predict anxiety
symptomology within this sample. These results must be viewed with caution considering
that all three groups’ means scores fell within normal anxiety and depression range. Similarly
caution should be raised considering the lack of statistical difference between the groups’
anxiety and depression mean scores.
Furthermore, this research found low levels of internal LOC to be a statistically
significant predictor of anxiety and depression symptomology contrary to the belief that only
external LOC predicts anxiety (for example, Molinari & Khanna, 1981; Presson & Benassi,
1996). Similarly, low levels of affective empathy were found to be a weak predictor of
depression symptomology. However, it was found not to be statistically significant when
taking into account occupation type. An unexpected outcome was the statistical significance
of high levels of affective empathy in predicting anxiety symptomology. A review of literature
research found no direct association thus future research will be beneficial in verifying and
determining this relationship. However the significance of this contribution was fairly weak
and must be interpreted with caution. Within this population sample no support was found for
the assumption that caregiver-well-being may negatively influenced by POS considering
both caregivers had higher mean POS scores than the control. The lack of negative
association between POS and psychological well-being does not provide additional evidence

to the reports suggesting that some res and dom care organisations are failing to financially,
socially, and operationally support their staff in the UK (for example, CQC, 2014; Franklin,
2014; Koehler, 2014). However, these findings must be viewed with caution considering the
small size of the sample. Additionally, the size of the response from the large number of
organisations approached to take part in the research must be considered. It may be inferred
that those organisations unwilling to participate may not have wanted to draw additional
attention to their service recognising operational flaws within. As such, a large proportion of
the consented organisations may reflect those outstanding services known to operate in the
UK (CQC, 2013, 2014), therefore attributing to the lack of significance in these findings.
However, this interpretation must be viewed with caution.
Future research must focus on extending the distribution range of questionnaires to
achieve a better representative sample. Furthermore, in finding a truer representation of the
impact POS may have on res and dom caregivers, a method such as focus groups (Denton
et al., 2002) to develop a self-report questionnaire based on caregivers views of support in
the workplace related to the quality assurance ideals presented by Eustis et al. (1993) and
well-being must be considered. This will enable the research to differentiate between what
impacts the role of caregiving and what impact the lack of organisational support has on
anxiety and depression as a means to develop specific methods of intervention.
References
Aggar, C., Ronaldson, S., & Cameron, I. D. (2011). Self-esteem in carers of frail older
people: Resentment predicts anxiety and depression. Aging & Mental Health, 15(6),
671–678. doi: 10.1080/13607863.2011.562176
Anderson, A. L. (1998). Strengths of gay male youth: An untold story. Child and Adolescent
Social Work Journal, 15(1), 55–71. doi: 10.1023/A:1022245504871

Austin, W., Globe, E., Leier, B., & Bryne, P. (2009). Compassion fatigue: the experiences of
nurses. Ethics and Social Welfare, 3(2), 195-214. doi: 10.1080/17496530902951988
Bartoldus, E., Gillery, B., & Sturges, P. J. (1989) Job-related stress and coping among
home-care workers with elderly people. Health and Social Work, 14(3), 204-210.
doi:10.1093/hsw/14.3.204
Blanco, V., Rohde, P., Vázquez, F. L., & Torres, A. (2014). Identification of caregivers at
greatest risk of major depression in two prevention studies. Psychotherapy
Research, 24(5), 578-593, doi: 10.1080/10503307.2013.847989
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital
Anxiety and Depression Scale An updated literature review. Journal of
Psychosomatic Research, 52(2), 69 –77. doi:10.1016/S0022-3999(01)00296-3.
Blumenthal, S., Lavender, T., & Hewson, S. (1998). Role clarity, perception of the
organization and burnout amongst support workers in residential homes for people
with intellectual disability: a comparison between a National Health Service trust and
a charitable company. Journal of Intellectual Disability Research, 42(5), 409-417. doi:
10.1046/j.1365-2788.1998.00150.x
Bowling, A. (2005). Measuring health: A review of quality of life measurement scales (3rd
ed.). Maidenhead: Open University Press.
Brady, T. J. (2003). Measures of self-efficacy, helplessness, mastery, and control. Arthritis &
Rheumatism (Arthritis Care & Research), 49(5), 147–16. doi: 10.1002/art.11413
Brouwer, W., van Exel, N., van den Berg, B., van den Bos, G., & Koopmanschap, M. (2005).
Process utility from providing informal care: The benefit of caring. Health Policy,
74(1), 85–99. doi: 10.1016/j.healthpol.2004.12.008
Butterworth, P., Pymont, C., Rodgers, B., Windsor, T, D., & Antsey, K. J. (2010). Factors
that explain the poorer mental health of caregivers: Results from a community survey
of older Australians. Australian and New Zealand Journal of Psychiatry, 44(7), 616-
624. doi: 10.3109/00048671003620202

Campbell, J. D., Chew, B., & Scratchley, L. S. (1991). Cognitive and emotional reactions to
daily events: The effects of self-esteem and self– complexity. Journal of Personality,
59(3), 473–505. doi:10.1111/j.1467-6494.1991.tb00257.x
Carré, A., Stefaniak, N., D’Ambrosio, F., Bensalah, L., & Besche-Richard, C. (2013). The
basic empathy scale in adults (BES-A): factor structure of a revised form.
Psychological Assessment, 25(3), 679-691. doi: 10.1037/a0032297
Castle, N. G., & Engberg, J. (2007). The influence of staffing characteristics on quality of
care in nursing homes. Health and Research, 45(5), 1822-1847. doi: 10.1111/j.1475-
6773.2007.00704.x
Chappell, N., & Dujela, C. (2008). Caregiving: Predicting at-risk status. Canadian Journal on
Aging, 27(2), 169–179. doi: 10.3138/cja.27.2.169
Chan, R. C. K., (2000). Stress and coping in spouses of persons with spinal cord injuries.
Clinical Rehabilitation, 14(2), 137-144. doi: 10.1191/026921500675826560
Chester, H, Hughes, J., & Challis, D. (2014). Commissioning social care for older people:
influencing the quality of direct care. Ageing and Society, 34(6), 930-950. doi:
10.1017/S0144686X12001249
Cleveland, J. N., & Shore, L. M. (1992). Self-perspectives and supervisory perspectives on
age and work attitudes and performance. Journal of Applied Psychology, 77(4), 469–
484. doi: 10.1037/0021-9010.77.4.469
Cohen, C., Colantonio, A., & Vernich, L. (2002). Positive aspects of caregiving: Rounding out
the caregiver experience. International Journal of Geriatric Psychiatry, 17(2), 184–
188. doi: 10.1002/gps.561
Colton, M., & Roberts. S. (2007). Factors that contribute to high turnover among residential
child care staff. Child and Family Social Work, 12(2), 133–142. doi: 10.1111/j.1365-
2206.2006.00451.x
CQC, (2013). Not just a number home care inspection programme: National overview.
Retrieved from: http://www.cqc.org.uk/sites/default/files/documents/9331-cqc-
home_care_report-web_0.pdf.

CQC, (2014).The state of health care and adult social care in England: 2013/2014. Retrieved
from: http://www.cqc.org.uk/sites/default/files/state-of-care-201314-full-report-1.1.pdf
Crown, W., Ahlburg, D., & McAdam, M. (1995). The demographic and employment
characteristics of home care aides: a comparison with nursing home aides, hospital
aides, and other workers. The Gerontologist 35(2), 162-170. Retrieved from:
http://gerontologist.oxfordjournals.org/content/35/2/162.full.pdf
CSSIW. (2014). National review of commissioning for social services in Wales 2014:
overview report. Retrieved from:
http://cssiw.org.uk/docs/cssiw/report/140416overviewen.pdf
Cummings, S. M., & Kropf, N. P. (2015). Predictors of depression among caregivers of older
adults with severe mental illness. Journal of Gerontological Social Work, 58(3), 253-
271. doi: 10.1080/01634372.2014.978927
Daly, M. (2008). Concerns over private care firms. Retrieved from:
http://news.bbc.co.uk/1/hi/scotland/7455711.stm
D’Ambrosio, F., Oliver, M., Didon, D., & Besche, C. (2009). The basic empathy scale: a
French validation of a measure of empathy in youth. Personality and Individual
Differences, 46(2), 60-165. doi: 10.1016/j.paid.2008.09.020
Davis C. M. (1990). What is empathy, and can empathy be taught? Physical Therapy,
70(11), 707–711. Retrieved from: http://www.physio-pedia.com/images/5/5b/Davis_-
_1990_-_What_is_empathy,_and_can_empathy_be_taught-annotated.pdf
Davis, M. H. (1983). The effects of dispositional empathy on emotional reactions and
helping: A multidimensional approach. Journal of Personality, 51(2), 167–184. doi:
10.1111/j.1467-6494.1983.tb00860.x
del‐Pino‐Casado, R., Pérez‐Cruz, M., & Frías‐Osuna, A. (2014). Coping, subjective burden
and anxiety among family caregivers of older dependents. Journal of Clinical
Nursing, 23(23-24), 3335-3344. doi: 10.1111/jocn.12561

Denton, M. A., Zeytinoğlu, I, U., & Davies, S. (2002). Working in clients' homes: the impact
on the mental health and well-being of visiting home care workers. Home Health
Care Services Quarterly, 21(1), 1-27. doi: 10.1300/J027v21n01_01
Dijkstra, M. T.M., Beersma, B., & Cornelissen, R. A. W. M. (2012). The emergence of the
activity reduces conflict associated Strain (ARCAS) model: a test of a conditional
mediation model of workplace conflict and employee strain. Journal of Occupational
Health Psychology, 17(3), 365-375. doi: 10.1037/a0028550
Edwards, A. B., Zarit, S. H., Stephens, M. A. P., & Townsend, A. (2002). Employed family
caregivers of cognitively impaired elderly: an examination of role strain and
depressive symptoms. Aging and Mental Health, 6(1), 55-61. doi:
10.1080/13607860120101149
Eisenberger, R., Huntington, R., Hutchison, S., & Sowa, D. (1986). Perceived organizational
support. Journal of Applied Psychology, 71(3), 500–507. doi: 10.1037/0021-
9010.71.3.500
Elfström, M. L., & Kreuter, M. (2006). Relationships between locus of control, coping
strategies and emotional well-being in persons with spinal cord lesion. Journal of
Clinical Psychology in Medical Settings, 13(3), 89–100. doi:10.1007/s10880-005-
9001-8
Eustis, N. N., & Fischer, L. (1991). Relationships between home care clients and their
workers: Implications for quality care. The Gerontologist, 31(4), 447-456. doi:
10.1093/geront/31.4.447
Eustis, N. N., Kane, R. A., & Fischer, L. R., (1993). Home care quality and the home care
worker: beyond quality assurance as usual. The Gerontologist, 33(1), 64-73. doi:
10.1093/geront/33.1.64
Farooq, A. (2009). Britain's Homecare Scandal. Retrieved from:
http://news.bbc.co.uk/panorama/hi/front_page/newsid_7986000/7986482.stm
Franklin, B. (2014). The future care workforce. Retrieved from:
file:///C:/Users/Alex/Downloads/Future_Care_Workforce_Report%20(1).pdf

Galambos, N. L., Fang, S., Krahn, H. J., Johnson, M. D., & Lachman, M. E. (2015). Up not
down: the age curve in happiness from early adulthood to midlife in two longitudinal
studies. Developmental Psychology, 1-8. doi: 10.1037/dev0000052
George, J. M., Reed, T. F., Ballard, K. A., Colin, J., & Fielding, J. (1993). Contact with AIDS
patients as a source of work-related distress: Effects of organizational and social
support. Academy of Management Journal, 36(1), 157–171. doi: 10.2307/256516
Geng, Y., Xia, D., & Qin, B. (2012). The basic empathy scale: Chinese validation of a
measure of empathy in adolescents. Child Psychiatry & Human Development,
43(40), 499-510. doi: 10.1007/s10578-011-0278-6
Gibson, R. C., Morgana, K. A. D., Abela, W. D., Sewella, C. A., Martina, J. S., Lowea, G. A.,
Hayea, W. De La., E dwardsb, C, L., O’Garoc, K. N., Reidd, M. E., & Asnanid, M. R.
(2013). Locus of control, depression and quality of life among persons with sickle cell
disease in Jamaica. Psychology, Health & Medicine, 18(4), 451–460, doi:
10.1080/13548506.2012.749353
Gray-Stanley, J. A., Muramatsu, N., Heller, T., Hughes, S., Johnson, T. P., & Ramirez-
Valles, J. (2010). Work stress and depression among direct support professionals:
The role of work support and locus of control. Journal of Intellectual Disability
Research, 54(8), 749–761. doi: 10.1111/j.1365-2788.2010.01303.x
Harvey, S., & Keashley, L. (2003). Predicting aggression in the workplace: risk factors, self-
esteem, and time at work. Social behaviour and Personality, 31(8), 807-814. doi:
10.2224/sbp.2003.31.8.807
Hatch, D. J., DeHart, W. B., & Norton, M. C. (2014). Subjective stressors moderate
effectiveness of a multi-component, multi-site intervention on caregiver depression
and burden. International Journal of Geriatric Psychiatry, 29(4), 406-413. doi:
10.1002/gps.4019
Hay, E. L., & Diehl, M. (2010). Reactivity to daily stressors in adulthood: The importance of
stressor type in characterizing risk factors. Psychology and Aging, 25(1), 118–131.
doi: 10.1037/a0018747

Hunter, C. E. A., Ward, L., & Camp, C. J. (2012). Transitioning spaced retrieval training to
care staff in an Australian residential aged care setting for older adults with dementia:
a case study approach. Clinical Gerontologist, 35(1), 1-14. doi:
10.1080/07317115.2011.626513
Jolliffe, D., & Farrington, D. P. (2006). The development and validation of the Basic Empathy
Scale. Journal of Adolescence, 29(4), 589-611. doi:10.1016/j.
adolescence.2005.08.010.
Kernis, M. H., Whisenhunt, C. R., Waschull, S. B., Greenier, K. D., Berry, A. J., Herlocker, C.
E., & Anderson, C. A. (1998). Multiple facets of self-esteem and their relations to
depressive symptoms. Personality and Social Psychology Bulletin, 24(6), 657– 668.
doi:10.1177/ 0146167298246009
Koehler, I. (2014). Key to care: Report of the Burstow Commission on the future of the
homecare workforce. Retrieved from http://www.lgiu.org.uk/wp-
content/uploads/2014/12/KeyToCare.pdf
Kramer, B. J. (1997). Gain in the caregiving experience: Where are we? What next?
Gerontologist, 37(2), 218–232. Retrieved from:
file:///G:/Dissertation/self%20esteem/self-esteem%20krammer.pdf
Lance Ferris, D., Lian, H., Brown, D. J., & Morrison, R. (2015). Ostracism, self-esteem, and
job performance: When do we self-verify and when do we self-enhance? Academy of
Management Journal, 58(1), 279-297. doi: 10.5465/amj.2011.0347
Lefcourt, H. M., Martin, R. A., & Saleh, W. E. (1984). Locus of control and social support:
Interactive moderators of stress. Journal of Personality and Social Psychology, 47(2),
378–389. doi: 10.1037/0022-3514.47.2.378
Lefcourt, H. M. (1991). Locus of control. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman
(Eds.), Measures of personality and social psychological attitudes (2nd ed., pp. 413–
498). San Diego, CA: Academic Press.
Lee, A., & Hankin, B. L. (2009). Insecure attachment, dysfunctional attitudes, and low self-
esteem predicting prospective symptoms of depression and anxiety during

adolescence. Journal of Clinical Child and Adolescent Psychology, 38(2), 219–231.
doi:10.1080/15374410802698396
Li, A., Shaffer, J., & Bagger, J. (2015). The psychological well-being of disability caregivers:
examining the roles of family strain, family-to-work conflict, and perceived supervisor
support. Journal of Occupational Health Psychology, 20(1), 40-49. doi:
10.1037/a0037878
Lobchuk, M. M. (2006). Concept analysis of perspective-taking: meeting informal caregiver
needs for communication competence and accurate perception. Journal of Advanced
Nursing, 54(3), 330-341. 10.1111/j.1365-2648.2006.03815.x
Lopez, J., Lopez-Arrieta, J., & Crespo, M. (2005). Factors associated with the positive
impact of caring for elderly and dependent relatives. Archives of Gerontology and
Geriatrics, 41(1), 81–94. doi: 10.1016/j.archger.2004.12.001
Lyons, K.S., Sayer, A.G., Archbold, P.G., Hornbrook, M.C., & Stewart, B.J. (2007). The
enduring and contextual effects of physical health and depression on care-dyad
mutuality. Research in Nursing and Health, 30(1), 84–98. doi: 10.1002/nur.20165
Marsh, H. W., Scalas, L. F., & Nagengast, B. (2010). Longitudinal tests of competing factor
structures for the Rosenberg Self-Esteem Scale: Traits, ephemeral artifacts, and
stable response styles. Psychological Assessment, 22(2), 366–381. doi:
10.1037/a0019225
McMullen, T., & Resnik, B. (2013). Self-esteem among nursing assistants: reliability and
validity of the Rosenberg self-esteem scale. Journal of Nursing Measurement, 21(2),
335-344. doi: 10.1891/1061-3749.21.2.335 .
Meurer, S. T. Luft, C. B., Benedetti , G. Z., & Mazo (2012). Validade de construto e
consistência interna da escala de autoestima de Rosenberg para uma população de
idosos brasileiros praticantes de atividades físicas (Construct validity and reliability in
Rosenberg’s self-esteem scale for Brazilian older adults who practice physical
activities). Motricidade, 8(4), 5-15. doi: 10.6063/motricidade.8(4).1548

Dissertation

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (11)

Similar to Dissertation

Similar to Dissertation (20)

Dissertation